Culture and Urban Mental Health

Culture and Urban Mental Health

Urbanization is probably the world's single most important demographic shift over the past century. In the early nineteenth century a mere 5% of the world's population was urban. In 1996, 46% of the world's population lived in urban areas. It is expected that in 2007 half of the world's population will be living in urban areas, and by 2030 the urban population will double and reach 5.1 billion. This massive growth is particularly evident in developing countries, especially in Africa and Asia (Figure). In Asia, the urban population currently constitutes 37% of the total population.1

Megacities—cities with over 10 million inhabitants—are rapidly increasing in number. Currently, 15 cities of this size exist but more are expected to proliferate over the next 3 decades, especially on the Asian continent. Although population growth is found in cities of all sizes, the fastest growth is in cities with populations in the 1 to 5 million range.1

The urban explosion affects mostly poor populations because growing cities fail to match the population expansion with proper infrastructure, housing, services, job opportunities, and economic expansion. This demographic change is significantly affecting both cities and rural areas. Today's cities are studies in contrast. They are agents of change—centers of finance, entertainment, and culture—offering opportunities for recreation, employment, and access to services; however, they are also reservoirs of crime, violence, poverty, and inequality.

Mostly because of increased speed and decreased costs of communication and transportation, cities are growing increasingly diverse in their population. Consequently, cultural factors have taken center stage in the understanding of urban mental health. This article will focus on the main approaches to urban mental health and briefly summarize the 3 lines of research in this area. It will then discuss the main themes of a vast body of literature on the cultural aspects of urban mental health.

Urban health penalty concentrates on unhealthy environments of inner cities, particularly in the United States where, over the past 50 years, the departure of the middle class and jobs to suburbs has left behind impoverished and increasingly segregated populations.

Urban sprawl concentrates on the
adverse effects of growth on health. A rise in obesity, sedentary lifestyle, and social isolation have been associated with urban sprawl.3

Urban living conditions focuses on physical and mental health as shaped by a variety of contexts. This is an integrated model that sees urban health as a function of individual factors affected by local, social, and physical environments.

Urban health advantage views urban living as an advantage when it comes to health. Some health indicators are better in urban than rural areas, especially in developing countries. In essence, the urban poor often fare better than the rural poor. In a demographic and health survey, infant mortality in poor populations was found to be lower in the urban setting than in the rural.4

Research models
The literature on urban mental health can be divided into 3 main categories, comparisons of urban versus rural, comparisons between cities, and features of urbanization and mental health.5 The urban-rural comparisons that were popular in the 1960s and 1970s, have recently become less frequent, in part because of conflicting results—some investigators found differences in prevalence of psychopathology while others did not—and also because they can only provide a snapshot of cities whose realities often change over time. For example, higher rates of mental illness have been described in urban compared with rural areas in the United Kingdom,6 while no differences were found in a similar study in Canada.7

The between-the-cities approach attempts to identify features that may have an impact on mental health, but by and large, findings may be hard to generalize to other cities or even to the rest of the city's populations.8
The third and currently in-vogue approach is to study discrete spatial units (neighborhoods or communities) to identify specific characteristics in small areas that are associated with specific physical and mental health problems. Because this approach is also context-specific, findings from this type of research are also not easy to generalize. Yet, this model, compared with the other 2, has the advantage of looking at discrete features of urban living; this approach leads to the ability to identify health outcomes and allows for a more focused, and therefore more likely to succeed, plan for intervention.

Cultural patterns in
today's cities
Cultural diversity
The increased opportunities for geographic mobility have produced an unprecedented multiethnic influx to cities. In New York, first-generation immigrants compose almost 10% of the population (50% of them from the Americas). In the borough of Queens, with its 250,000 inhabitants, there are 80 different languages spoken from 123 different countries. The United States' cultural and ethnic composition is rapidly changing. Demographers project that by the year 2050, 1 of 4 US inhabitants will be of Spanish decent.9

The complexities of cultural aspects that impact psychopathology and mental health are producing both challenging and beneficial changes in the way psychiatry is practiced. The negative aspects of such multiethnic migration, however, may include lack of familiarity with illness presentation, culturally specific belief systems, and reluctance to rely on medical systems—all of which may significantly delay proper assessment and treatment. The multiculturalism of today's cities contributes to increased tolerance, better quality of life, and sociocultural stimulation; at
the same time, it often contributes to heightened social tensions, interethnic striving, and cultural conflicts—all of which undoubtedly carry mental health ramifications.